Empowering you to take an active role in your healthcare.
Our Discharge Planning Program is designed to provide you with the knowledge and skills needed to manage your conditions and transition successfully. Discharge planning begins upon admission and continues throughout your stay. The interdisciplinary team assesses your ongoing progress, identifies your goals, and provides any necessary education need to support and prepare for your safe discharge home or to a lower level of care. We work to engage you, your family, and caregivers in the discharge transition process, with the goal of reducing adverse events and preventable readmission to the hospital.
We understand that recovering from an unexpected injury or illness is not easy. Throughout your stay, your care team will specifically address your questions and concerns, making sure you are fully prepared for your transition home.
The Discharge Planning Program includes the following key elements:
- Education on the resident’s condition, the discharge process, and the next steps throughout the resident’s stay.
- Engaging residents and families in the discharge planning process.
- Discussion on how to prevent potential problems at home, including how to spot warning signs and who to contact if there is a problem.
- Review of what life at home will be like following discharge: home environment, support needed, dietary restrictions, and modified activities.
- Review of medications: management, administration, potential side effects.
- Follow-up appointment planning.
For residents transitioning directly from hospital to home, our Care Transitions Program is designed to help you play a more active role in your health care and prevent the likelihood of rehospitalization. This 3-phase journey follows you every step of the way to make sure you are receiving the right level of care to get you back to your highest level of independence and quality of life.
Your transition coach first visits you in the hospital to arrange a post-discharge home visit and to provide you with a personal health record. This record, which you will be instructed to share with future health care providers, includes a list of your health problems, medications, allergies, and warning signs/symptoms to closely monitor.
During your post-discharge home visit, which will take place 48-72 hours after your discharge from the hospital, your transition coach will:
- Review your prescribed medications to confirm there are no dangerous interactions.
- Discuss your medication regimen with you.
- Teach you how to effectively communicate your needs to your healthcare professionals.
- Review “red flags” or warning signs/symptoms in your health record, including how to manage them and when to contact a doctor.
After your home visit, your transition coach follows-up with three telephone calls during the first four weeks after your hospital discharge to make sure you have received necessary medical services, medications, and equipment, and to discuss and answer any questions you may have about recent medical appointments.
At EmpRes, resident satisfaction is a top priority. We believe that being proactive versus reactive is paramount in resident care. That’s why we have developed the “4 R’s of Resident Satisfaction,” a systematic rounding program with the singular goal of making sure our residents’ needs and wishes are met. EmpRes employees are trained on the principles of the “4 R’s of Resident Satisfaction” on a regular basis. Look for the “Ask Me About the 4 R’s” button on your caregiver that shows they have successfully completed the training.
The “4 R’s of Resident Satisfaction” address the following principles:
1 – Relief
We want to relieve any and all pain.
What do you need to relieve your pain? It could be assistance moving to a new position, relaxing music, additional pillows, or a call to the licensed nurse to review pain medication.
2 – Reposition
We want our residents to be comfortable.
Do you need a pillow rearranged or an extra blanket? Perhaps you would like assistance moving from the bed to your chair? We are happy to make sure you are as comfortable as possible. We will also turn residents at risk of pressure ulcers and adjust arms, legs, and head rests for comfort.
3 – Restroom
We want our residents to be safe and dry.
Your restroom needs and schedules are checked, as needed, and assistance is provided for bedpans or briefs. Our goal is to avoid unsafe behaviors related to toileting, such as falls.
4 – Reach
We want our residents to have what they need.
If you need anything that is out of reach, we will make sure to get it for you. This includes the TV remote, call light, over bed table or light, telephone, water, personal items such as glasses and dentures, and any other frequently used items. We will make sure your shoes or slippers are at your bedside for ease of use if you need to get up.
Our Virtual Care Technology program allows us to provide a superior in-home experience by enabling secure, compliant, reliable, and organized communication between patients and their care team. Our Virtual Care Technology (VCT) program connects patients daily to a nurse via the use of next-generation telehealth and telemedicine technologies. VCT devices measure blood pressure, pulse, weight, oxygen saturation, and blood glucose levels. Information is relayed to our VCT nurse, who makes an assessment and coordinates follow-up as needed. If a reading is outside parameters established by the patient’s physician, action is taken. This program is proven to reduce hospitalization and emergency room visits, while building patient confidence to self-manage their conditions at home.
Real-time patient engagements include:
- Remote Monitoring of Vital Signs
- Medication Reminders
- Secure Video Visits
- Incident Recording
- Event Alerts
- On-Demand Access to Education
- Surveys and Feedback Modules
- Eden Health Provider Access